Contradictions and Interventions in Health IS

In 2014, the hospital administration decided to replace the legacy PDMS (hitherto CareSysOld). CareSysOld was first implemented approximately 20 years ago and was used in all 15 critical care units of the hospital. Over the years, IT and medical stakeholders made great efforts to align CareSysOld with the existing and emergent characteristics of the activities performed in the critical care units. However, the PDMS no longer complied with Germany’s Medical Device Act (implementing EU Directive 93/42/EEC, 2007/47/EC, Article 1, 2a). Further, physicians increasingly asked for advanced medical decision support functions, which were not supported by CareSysOld. Thus, implementing CareSys was primarily aimed at ensuring compliance with new regulatory requirements and improving advanced medical decision support functions.

The high-level requirements that guided the selection of a successor PDMS were primarily developed in alignment with functionalities inscribed in CareSysOld. In developing these requirements, the involved IT professionals were able to draw on their experiences and practical knowledge as former nurses and also integrated the input of selected physicians. Potentially suitable software packages were then evaluated by clinical and administrative users as well as IT professionals.

In 2011, the hospital started an initiative to gradually implement PatientDoc as an additional HIS for care documentation in all nursing-intensive wards, including internal medicine, gynecology, and psychiatry. In total, it was anticipated that PatientDoc would be deployed in 26 general wards to improve compliance with legal requirements (i.e., resolve contradictions between the tools and current regulations), increase the efficiency of day-to-day clinical activities, optimize reimbursement, and so forth. One of the project goals was to develop a standardized core of PatientDoc that would be adapted to the specific requirements of the hospital but identical in all wards. This core was built on templates provided by the vendor and included approximately 80% of the functionalities needed in all wards. The remaining 20% were identified as ward-specific and were added as customizations prior to the rollout in each ward.

When we started data collection, PatientDoc had already been implemented in 9 of 26 general wards. Thus, the project team had already gained significant experience in implementing PatientDoc and had defined most of the core functionalities used in all wards. Moreover, the team had gained experience with the various best-practice templates that the vendor provided for various medical specialties and had begun adapting them to ward-specific requirements. For this study, we observed the rollout in the “Addictive Psychiatry” ward.

We found CareSysOld to be well-aligned with other elements of the activity system within the wards observed, i.e., the critical care units. This is not surprising because CareSysOld was constantly adapted over the years to fit the specifics of the activity systems in different wards. However, CareSysOld was not compliant with regulatory requirements induced by the organizational environment (Medical Device Act, hereafter MDA). Thus, we identified a contradiction between the activity system elements of tools (CareSysOld) and rules (regulatory requirements). Furthermore, the system was highly customized and difficult to stably operate and did not provide the increasingly demanded enhanced decision support capabilities for physicians, which we identified as a contradiction between the activity system elements of tools and subjects. This contradiction was also caused by the limited range of patient and treatment data that could be recorded in a structured way with CareSysOld.

Looking at the rules and the division of labor that govern patient treatment in the ward, we found some noteworthy characteristics. Firstly, from a legal perspective, physicians have almost sole decision-making authority, while the nursing staff is responsible for doing the “groundwork” (e.g., collecting data) and executing care-related treatment decisions (e.g., administering drugs). Moreover, we observed that the interactions between the actors are shaped by definitive roles and task assignments within and between different professional roles. This was, for instance, observable during the case discussion sessions. Here each patient’s health status, current treatment, and medical history – the cases – were discussed based on the data recorded in CareSysOld. Using CareSysOld, the responsible physician could quickly outline the treatment plan and the patient’s health status and the nurses could report their activities. The chief physician would then ask questions and decide on adaptations to the treatment plan. Each single patient case was reviewed very quickly. Once the case discussions were finished, the nursing staff was required to execute the decisions, document their activities, and collect further data to be discussed during the next session. Nurses were responsible for documenting and updating the treatment plan and administering all prescriptions, documenting their own activity, and documenting the patient’s health status. These tasks require a considerable amount of time, during which nurses were unavailable to care for patients. Here, we found a latent contradiction between the subjects, division of labor, and object that did not surface because CareSysOld provided sufficient flexibility to reorganize the task distribution and to assign documentation tasks to volunteers or trainees. This, in turn, allowed subjects to allocate more time to the object – namely, patient health status. In that regard, CareSysOld was found to be an integral part of this and other parts of the activity system in that it facilitated coordination between the different medical specialties, was well-aligned with the requirements of the various professional roles and specialties, and reflected the culture in the wards (e.g., “command and control” during case discussions). However, during our interviews we observed a contradiction between how physicians and nurses view patient health status as the object of their common work activity: while physicians want to learn as much as possible about patients and expect nurses to collect most of this data (i.e., change of vital data), nurses want to care for the patient as directly as possible. That is, there is a contradiction between the activity system elements of subject and object in that different subjects (physicians and nurses) have contradictory motives toward the object of the activity system. This contradiction was latent, as it had no observable dysfunctional effect on the activity. This contradiction was masked by CareSysOld, which was efficient for nurses to use because it, for example, allowed the use of shortcuts for data entry. CareSysOld did not force nurses to enter all the detailed data desired by physicians, thus allowing them to report only data that was meaningful from their perspective, leaving more time for patient care.

Furthermore, the already mentioned latent contradiction between the activity system elements of subject and object, where different subjects (physicians and nurses) had contradictory motives toward the object of the activity system, surfaced and became salient because the new system required all the detailed data that physicians wanted and did not allow for short-cuts. Therefore, while physicians got the information they demanded (“most things are available,” CS-PH3), nurses had to devote much more effort to documentation (“it may fulfill the needs of ‘Mr. Professor’, but not those of a nurse,” CS-NU03). Mostly due to ensuring conformity with the MDA, CareSys was less adapted to the historically evolved processes and the specifics of the different wards. In addition, while CareSys offers the ability to record a much wider range of data, since not all data is relevant for all medical specialties, this can lead to crowded interfaces (“too big, too confused, too complex, too much”, CS-NU01). Because they were tasked with recording all data “demanded” by CareSys, nurses’ documentation efforts significantly increased, thus reducing the time available for direct patient care (“We are facing additional work time of up to a half hour per patient,” CS-NU01 and CS-NU02). The relatively strict “command and control” culture in the wards that was now encoded in CareSys made the situation even worse: the nurses did not question whether they had to collect all data for every patient. Rather, they tried to provide all the data CareSys requested, even though not all fields are relevant for all patients in all wards. This, in turn, surfaced the latent contradiction that, while present with the old HIS, did not previously manifest as a problem or a breakdown. Overall, the nurses were deeply disappointed when CareSysOld was replaced by CareSys, particularly because they had less time to do what motivates them – take care of patients.

However, the nurses were not the only actors who were upset. Although CareSys offered the requested enhanced diagnostic features, physicians also had difficulties letting go of the procedures that had been in place for decades. In the case review setting, for instance, CareSys did not enable physicians and nursing staff to quickly recall patient and treatment status and – even more importantly – did not allow them to answer the chief physician’s questions nearly as quickly as before (“I am clicking myself to death,” CS-NU01). The amount of data available in CareSys and the specifics of the user interface made it difficult to get an overview of the data quickly and to fulfill traditional roles during case reviews. As with other observed incidents, it was only during the rollout that the project participants determined that although CareSys fulfills the requirements of the MDA, it is not flexible enough to adapt to the traditional structures in the wards that had shaped the activity system for years. These traditional structures involved, for example, assigning documentation and data retrieval tasks to trainees or volunteers to cope with requirements of data collection and retrieval, thus freeing up capacity for physicians and nurses, who could in turn allocate more time to the object. The new HIS hardwired a specific distribution of tasks; consequently, the traditional distribution of work and responsibilities among physicians, nurses, and other actors, such as trainees or volunteers, no longer worked. Accordingly, the previously mentioned latent contradiction between subjects, division of labor, and object became salient, as the new HIS implied a change in the division of labor. However, since nurses did not agree with the change, this caused disturbances between subjects and the object because treatment could no longer be efficiently provided.

Overall, implementing the new HIS – CareSys – significantly disrupted patient treatment activities and noticeably reduced efficiency. Both physicians and nurses perceived CareSys as “too overloaded” (CS-NU3), “complex” (CS-PH3), and “inflated” (CS-PH1). Overall, the issues led nurses to demand a rollback of CareSys and to resist using CareSys if it did not jeopardize patient safety. Management interventions after the rollout, as well as unintended balancing mechanisms that led to adaptions of complementary elements of the activity system, mitigated the contradictions and reduced negative effects. For instance, each ward announced explicit instructions regarding the specific data that needed to be collected. This intervention led to reduced documentation efforts so that nurses could once again focus more on direct patient care. In addition, physicians and nurses began to maintain an additional paper-based summary of the most important information for case reviews.

In contrast to the CareSys implementation, where a predecessor information system existed (see Sect. 4.1), in the wards under study in the PatientDoc case, predominantly paper-based tools were used to document and review patient data. On the one hand, these paper-based tools limited the possibilities of physicians, as the scope of structured documented data was restricted and it was not possible to apply extended diagnostic functions based on the available data. Moreover, because of the restricted scope of structured documented data, the paper-based documentation impeded management efforts to invoice medical services comprehensively and efficiently with insurance companies and other payers. Thus, there were clear contradictions between subjects and tools, as the paper-based tools did not for allow extended diagnostic functions and efficient reimbursement. Looking at the exchange value of the activity, important managerial aspects of patient treatment could not efficiently be performed, particularly in terms of complete and comprehensible reimbursement requests.

The paper-based documentation tools were found to be well aligned with complementary elements of the activity system and they successfully balanced the, to some extent, opposing requirements of physicians and nursing staff for a long time. Here, as in the CareSys case, we identified a latent contradiction between the activity system elements of subject and object rooted in the different motives of the subject groups (physicians and nurses) toward the object of the activity system. Physicians demanded more information for diagnostic purposes, requiring nurses to devote more effort to collecting and documenting, which reduced the amount of time available to nurses for patient care. Also, as we will see below, the paper-based documentation tools provided enough flexibility to enable physicians and nurses to deal with the ever-increasing workload in the wards (induced by the organizational environment) and allowed them to make most of their specific competencies and experiences. For instance, although the physicians and nurses working in the Addictive Disorders ward had developed an effective medication management procedure over time (local, ward-specific, implicit rule), this approach may not have been fully compatible with legal requirements: by law, nurses are only allowed to administer drugs as prescribed by a physician. However, since physicians are not always physically present in the ward, this sometimes created problems; in certain situations (e.g., emergencies), nurses needed to adapt the dosage intervals themselves and then get authorization by phone (e.g., in cases of acute delirium, restlessness, or shivering). Moreover, we found that physicians were not always entirely comfortable in setting the dosages without consulting a nurse. They even asked whether it “is possible to calculate the optimal dosage within the system” (observation note). Therefore, following implicit, ward-specific rules enabled the involved actors to effectively care for their patients. Moreover, the flexibility offered by the paper-based tools enabled the physicians and nurses to ensure that they avoided legal problems. A similar example relates to trainees and volunteers. In some wards, the way that tasks were distributed was continuously adapted in order to cope with increasing cost pressures and workload. Volunteers and trainees were increasingly asked to measure and document vital parameters. Though supervision by a certified nurse and authorization of the documentation is legally required, volunteers and trainees frequently performed these actions on their own. This saved valuable nursing time, which could then be allocated to direct patient care. In that regard, like in our other case, CareSys, we identified a latent contradiction between the activity system elements of subject, division of labor, and object that did not surface because of the flexibility of the paper-based tools. Physicians and nurses (subjects) developed an efficient task distribution (division of labor) which, for example, “allowed” for medication prescribing by experienced nurses and documentation by volunteers. This freed up physicians’ and nurses’ capacity, allowing them to devote more time to patient care, thus supporting patient health status (object). Overall, the paper-based documentation tools were able to balance divergent needs, cushioned contradictions, and prevented problems and breakdowns within the activity system; thus, the latent contradictions did not surface in the old system.

First, PatientDoc rendered existing modes of task distribution impossible. Although it was previously known that, in compliance with IT policy, volunteers did not possess user accounts authorized to perform documentation in PatientDoc, this only became problematic after the rollout, because only nurses and trainees were able to document vital parameters. Thus, the evolved division of labor was no longer applicable and the efforts that nurses were required to devote to documentation increased considerably. Nurses now had to spend more time recording vital parameters on their own or accompanying volunteers and trainees. PD-NU01, for instance, stated that nurses now “spend too much time at the computer and have less time for the patients”; also, many nurses did not want to key in data they did not collect (“I will not key in data that I have not measured,” PD-NU03).

As discussed above, we identified different motives of the subjects (physicians and nurses) toward the object of the activity system. Physicians demanded more information for diagnosis purposes to better fulfill their object-related tasks and nurses wanted more time to care for patients in order to better fulfill their object-related tasks – improving patient health status in both cases. However, since more information for diagnostic purposes requires data collection and documentation to be carried out predominantly by nurses, there seemed to be a trade-off that had been balanced prior to the implementation of PatientDoc. For example, the nurses in the Addictive Disorders ward created and gradually refined “monitoring sheets” for every patient. These sheets hung on the blackboard and helped nurses to keep track of patients (e.g., in case of emergency and during shift handovers) and provide optimal care to patients. Vital parameters, adapted dosages, and other important events were recorded on these sheets before the formal documentation was updated. For nurses, this was an efficient way to perform documentation tasks.

In order to reduce these unintended effects, management interventions to adjust the structure of the activity system were necessary. To ensure compliance with legal regulations, management implemented extended planning periods and IS-supported identification of appropriate medication schemes for critical drugs to prevent short-term adjustments. In addition, management directed physicians and nurses to document medication adjustments before administration, even if no physician was on site. To smooth these operations, physicians were trained to document adaptations remotely. Likewise, management gave trainees and volunteers permission to use the accounts of trained nurses to record vital parameters, explicitly legitimizing this practice, even though went against IT policy regulations. Moreover, although management discontinued the use of the monitoring sheets, they installed large screens in the ward rooms for displaying patient reports and provided notebooks to ease ward rounds and shift handovers.

Drawing on AT, we specify misalignments as contradictions between elements of the activity system. Per se, contradictions are inherent in all human activities, as they are rooted in a given primary contradiction between the use value (i.e., the needs an activity fulfills, such as improving patient health) and the exchange value (i.e., the commercial value, such as productivity gains) (Engeström 1987). Building on AT, we conceptualize IS implementation projects as a means to deal with the manifestations of these primary contradictions. In our cases, the PDMS were introduced to the activities to balance patient safety (i.e., use value) and efficiency of patient care (i.e., exchange value). Extending prior research, this paper shows that the concept of contradiction can be used as a conceptual tool to not only identify and analyze but also to theoretically explain different grounded root causes of post-implementation issues (Strong and Volkoff 2010).

Looking at the patterns of the problematic interrelations, one novel contribution is that we found triads of conflicting elements, as opposed to the dyads that past research dealing with IS post-implementation issues has focused on, in terms of either the user (i.e., subject) and the IS (i.e., tool) or the IS and process requirements (i.e., rules and distribution of labor) (see e.g., Boudreau and Robey 2005; Berente et al. 2016; Oborn et al. 2011; Strong and Volkoff 2010). This finding indicates the need to broaden the scope of interrelations between the elements that define the context of HIS implementation to explain possible dysfunctionalities that emerge after implementation. Using the concept of activity systems, we identified contradictions within four constellations of rules, division of labor, subjects, and object that emerged after adding the HIS to the activity system and manifested as post-implementation issues, negatively affecting the functioning of the activity system and, thus, its outcome.

This study reveals that HIS implementation risks facilitating the emergence of new manifestations of primary contradictions but also causes the manifestation of latent contradictions. The latent contradictions we identified were amplified by the newly implemented HIS and became salient only after the IS changed the relationship between the subjects and the object of the activity. Groleau et al. (2012) argues that these latent primary contradictions between commercial and professional poles (i.e., use and exchange value) embodied in the relationship between the subjects and the object may surface as salient contradictions once new means or methods are introduced. This study not only adds evidence to this finding, we also show that the opposition between use value and exchange value defines the interrelation between the tools employed and other elements of the activity system, such as the division of labor. The interplay between these elements and the tools used may mitigate the effect of these contradictions and prevent them from manifesting as problems. In the cases analyzed here, the flexibility of the paper tool created an interdependent, complementary duality and allowed a mode of task distribution to evolve that covered up the contradiction (cf. Wareham et al. 2014). The HIS, though it resembles the functionalities of the paper-based tool, had the potential to dissolve what Jay (2013, p. 137) refers to as the “latent organizational paradox,” causing hitherto latent contradictions to manifest as post-implementation issues by managing contested perspectives regarding the object of the collective work differently. This may then cause already embodied latent contradictions to manifest as post-implementation issues. This again highlights that IS-related impositions not only emerge from the functionalities of the IS (Strong and Volkoff 2010) but are created by the dynamics of “the ‘binding’ of time–space” in activities (Giddens 1984). Thus, we answer the call for a better understanding of contextual complexities in IS research and further specify this call by emphasizing the need to analyze the wider historical trajectory of an activity in the context of all its elements and their relationships in order to make sense of post-implementation issues. At the same time, we show that an awareness of latent and salient contradictions in activity systems enables a better understanding of the post-implementation issues that may emerge in one context but not in another.

Prior literature has already analyzed the effectiveness of several intervention strategies that aim to mitigate misalignments between an IS and users practices, such as workarounds (Boudreau and Robey 2005), the dynamic adjustment of practices (Berente et al. 2016), alignment across different disciplines (Oborn et al. 2011), and adaptations to technology (Wei et al. 2005). However, most extant research focuses on interventions affecting single elements of an activity system. We contribute to this research by showing that management interventions need to account for the complex interactions of all elements of an activity system. This corresponds to our finding that contradictions may often affect more than two elements of the activity system, and hence effective interventions geared to resolve those contradictions must account for this higher level of complexity. Accordingly, before choosing and implementing interventions, a sound understanding of the root causes of post-implementation issues is required (i.e., the contradiction within the activity system), which may not be limited to an IS and its users. Instead, our study shows that addressing post-implementation issues may require interventions beyond tackling the IS and user actions, such as interventions dealing with the division of labor or rules that govern the collective activity. Moreover, in terms of latent contradictions that are already inscribed within the activity prior to implementation, the case study also indicates that these contradictions tend to require interventions that focus on complementary elements of the activity system. However, identifying such contradictions is apparently difficult during daily work routines. In line with AT and other theories that conceptualize mediated human activity, elements that define an activity but are not in focus during IS implementation and are not (yet) causing issues, usually receive little attention (Riemer and Johnston 2013). However, implementing a new IS as a tool would most likely impact the complex interrelations among those elements.

Post-implementation issues that are linked to contradictions rooted in broader socioeconomic contexts, such as the conflict between use value and exchange value, are more difficult to resolve. In such cases, a single intervention may not be sufficient. Rather, multiple interventions geared toward addressing different elements simultaneously are often necessary to mitigate the issues associated with such contradictions. Thus, the combination of interventions across elements matters. The data also indicates that the element on which effective management interventions focus is always part of the contradiction that should be mitigated. Through using the concept of the activity system, this study contributes a theoretically grounded means of relating interventions to specific elements. This offers a foundation upon which further studies could analyze interventions, their interrelationships, and their effects more specifically, e.g., whether interventions geared toward subjects are better suited than interventions geared toward other elements to counter contradictions. Moreover, further research should focus on identifying the necessity and effects of complementary interventions.

Finally, our findings indicate that it is possible to avoid contradictions related to divergent motives by combining the introduction of a new tool with changes in other elements of the activity system, either up-front or through interventions counterbalancing unintended contradictions. This topic relates to the argument that pursuing humanistic goals entails positive actions which, in turn, amplifies synergistic solutions (Sarker et al. 2019). As already mentioned, the humanistic goal of physicians and nurses was almost identical and related to improving patient health status. However, the motives (ensuring better data for diagnoses; securing more time to care for patients) and, consequently, the means of achieving this goal differed across the subject groups. Finding a synergistic solution involved securing both better data for diagnosis as well as more time for patient care, outcomes that should amplify each other and lead to even greater improvements in patient health status. Thus, even if motives diverge, it is often possible to identify a synergistic solution, rather than a solution involving a trade-off between motives.